Ischemic heart disease resulting in acute myocardial infarction leads to over 1,000,000 hospitalizations every year in the United States. Lack of clear diagnosis has been reported as one reason for suboptimal use of proven treatments. The Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) assists in the diagnosis of acute cardiac ischemia and has been shown to improve the diagnostic accuracy in the triage of patients cardiac ischemia. The ACI-TIPI prints a probability score on the electrocardiogram report from 0-100% that the patient is truly suffering acute cardiac Ischemia. The primary aim of this pilot project is to study the effect of implementing and utilizing the ACI-TIPI software in rural emergency departments. This pilot project will be a controlled clinical trial on the impact of the ACI-TIPI on diagnosis and triage of patients presenting with symptoms suggestive of ischemic heart disease, Because the ACI-TIPI has not been studied in rural hospitals we will also collect data on the process of implementing this new technology in rural hospitals. The study will take place in the High Plains Research Network (HPRN) which consists of 8 hospitals from 6-40 beds, 50-180 miles from the closest tertiary care hospital. The ACI-TIPI software will be installed in the necessary ECG machines in each of the 8 hospitals. When turned on, the ACI-TIPI software provides the printed probability report along with the standard ECG interpretation report. When off, only the standard ECG report is printed. The trial will he carried out over 10 months. Each month the hospitals will alternate between control (ACI-TIPI report off) and intervention (ACI-TIPI report on). When complete we will have 5 months of intervention and 5 months of control data from all 8 hospitals for approximately 500-600 patients. We will compare the diagnostic accuracy and the rates of discharge, admission, and transfer between patients evaluated during intervention and control months. Each patient case will he reviewed and diagnoses of acute ischemic heart disease will he confirmed on the basis of presentation and clinical course, initial and follow-up electrocardiograms, and serum cardiac enzymes using standard criteria. Implementation data from surveys and interviews on use of the ACI-TIPI will be analyzed independently to allow for full, unbiased generation of themes and hypotheses. They will then he analyzed across communities to identify common challenges, barriers, and successful implementation features. The final product will he a thorough report on the key lessons learned in the implementation of the ACI-TIPI system into rural hospitals. This pilot project will inform future efforts to implement new technology, specifically the ACI-TIPI, into rural emergency care and will support continued quality improvement in the care of patients suffering acute myocardial infarction.